Peds exam 1- integumentary considerations

Structure of the skin

Epidermis → dermis → hyperdermis → muscle

Pediatric skin considerations

• thinner epidermis and stratum corneum until 2nd year of life

• higher epidermal cell turnover rate

• immature eccrine sweat glands and sebaceous glands- don’t sweat as much

• lower natural moisturizing factor

• less melanin

• less subcutaneous tissue

• dermis/ epidermis loosely attached

• pH close to neutral (6.6-7.5); adult skin pH is 4.5-6.7

  • the neutral pH has less ability to fight infections, more bacteria grow (diaper rash ex)

Impacts of peds skin

• immature barrier function

• more susceptible to

  • heat and water loss

  • superficial bacterial infections

• heightened UV light- at least 30 spf, 50 recommended

• young children with skin conditions are more likely to have associated systemic manifestations

• skin of infants and young children is more likely to react to primary irritant

• skin prone to blistering and separation

• avoid topical iodine or chlorohexidine in <2 mnths old due to high permeability of skin- risk of going into blood stream

Human considerations with skin

• hypopigmentation or hyperpigmentation possible following the healing process of dermatological conditions

• hypertrophic scars (not beyond border of initial cut) and keloids (goes beyond border of initial cut) are more common in those with darker skin tones

• important to note that some rashes will look different on darker skin tones than the widely- accepted description

Role of the nurse in skin disorders

• education on causes, prevention, and treatment modalities

• infection control; prevention of secondary infections

• education regarding management

• accurate documentation on appearance of lesions

Describing skin lesions- color

• red, pink, wine, blue, yellow, orange, grey, black, erythematous (red, nonblanching, swelling redness)

Describing skin lesions- size

• “pin prick”, “quarter size”

• or an actual measurement in mm or cm

• can use pen to outline and measure if growth or gotten smaller

Describing skin lesions- morphology

• form and structure (is it flat, elevated, or depressed below the plane of the skin?)

Describing skin lesions- distribution

• single or multiple

• pattern or scattered

• symmetric/ asymmetrical

• sun?

• full diaper area vs sparing creases

Describing skin lesions- arrangement

• clustered

• diffuse

• linear

• lacy

• circular

• bullseye

• snakeline/ reticulated

• confluent

• grouped (connected to other sections)

Describing skin lesions- location

• palms, scalp, perineum, axilla, feet, toes, mucosa, trunk, extremities, ears

Describing skin lesions- how it is to touch

blanching vs non-blanching

What is congenital dermal melanocytosis?

• formally known as “mongolian spots”

• slate grey or bluish nevi noted at birth on the backs and/or buttocks, primarily in people with darker skin or of asian/ african descent

• looks like deep bruising

• nursing considerations: document closely and follow at routine visits

• treatment: none, usually fades over times and disappears by puberty

• kids born with not from touch; if changes drastically or gets worse, could be actual bruising and needs to be followed closely to monitor for potential abuse

What is infantile hemangioma?

• known as a “strawberry mark"

• benign birthmark which is caused by an extra collection of blood vessels growing where they are not needed

• most commonly found on face, neck, head

• treatment: typically self-resolving, dependent on size and location, may give propranolol (beta blocker- low dose)

What is acanthosis nigricans?

• velvety hyperpigmentation of skin, often found in folds under arms or around neckline

• Nursing considerations: associated with obesity, pre-diabetes, or insulin resistance- indicates need to screen for diabetes

  • can also been seen with PCOS

• Treatment: none, investigate underlying cause

What is scabies?

• burrows caused by sarcoptes scabiei

• nursing considerations:

  • burrow under/ between skin

  • not related to poor hygiene

  • rarely affects face and scalp; common in groin, buttocks, webs of fingers, and in folds of wrist

  • itch is worse at night

• treatment: topical or oral pediculocide

  • permethrin or ivermectin

  • whole household needs to be treated- if family member with it

What is head lice?

• louse can live in the hair, eyelashes, eyebrows of humans

• life cycle is 1 month for 1 louse

• females lay 7-10 eggs daily at hair shafts

• nursing considerations:

  • “no-nit” policy is no more; kids do not get sent home right away for psychosocial development

  • education, identification

    • lice travel head to head by sharing- hats, touching, coat, headbands, etc. they do not jump

• Treatment

  • teach children not to share hats, scarves, combs

  • wash fomites

  • comb!!!

  • pediculocides (permethrin= Nix)

  • home remedies- clothes and linens need washed in high heat, family doesn’t need tx unless have eggs themselves-prevent and monitor; may need to “suffocate” eggs, mayo, teatree oil, etc

• often behind ears and back of scalp

Exanthems

• a widespread rash (reactive rash) accompanied by systemic symptoms such as fever, headache, malaise

What are exanthems?

• viral or bacterial etiology:

  • reaction to toxin produced by organism

  • damage to skin by organism

  • immune response to organism

• drug etiology

  • antibiotics

  • anticonvulsants

  • NSAIDs

  • allergies can cause these rashes like penicillins and amoxicillins

• when to raise concern

  • when rash becomes systematic- fever, rash won’t go away, worry about seizure, anaphylaxis, dehydration- monitor I&Os

Six classic childhood exanthems

• first disease- measles, rubeola

  • measles virus

• second disease- scarlet fever

  • streptococcus pyogenes

• third disease- rubella, german measles

  • rubella virus

• fourth disease- filatov-duke’s disease

  • obsolete classification

• fifth disease- erythema infectiosum

  • human parvovirus B19

• sixth disease- roseola, exanthema subitum

  • human herpes virus 6

Viral rashes- Varicella Zoster (chickenpox)

• very contagious and itchy

• following chicken pox infection, the varicella virus remains in select cells of the dorsal root ganglion in the spinal cord. It may be stimulated to reappear later in life as herpes zoster aka “shingles”

  • shingles follows the dermatome and is VERY painful

  • develop immunity by self exposure before vaccine became popular and trusted

• *this is vaccine preventable: 1 dose at 12-18 months old, 1 dose at 4-6 years

• tx/ manage symptoms- untreatable, runs its course

• shingles vaccine at age 60-65 as well

• rash starts on face typically, very itchy, runny nose and cough, sores can appear in mouth, rash spreads to chest back and tummy then to arms and legs

• chickenpox follows dermatomes

Viral rashes- molluscum contagiosum

• viral warts caused by a virus in the pox family

• usually skin-to-skin contact or fomites

  • very contagious

  • ex. from wrestling mats, swimming, hockey equipment

• higher incidence in:

  • immunocompromised people

  • those who swim frequently

  • wrestlers

  • those whose skin barriers function is otherwise compromised

• generally self-limiting though may persist for months to years

  • can freeze off, but not only tx- very deep

bacterial rashes: impetigo

• caused by staphylococcus- which is on all of our skin

• increased susceptibility with breaks in skin (insect bites, minor trauma, eczema)

• *golden, honey, crusted lesion

• nursing considerations:

  • contagious while open pustules

  • education: hygiene to prevent spread

  • treatment:

    • topical antibiotics (mupuricin) usually x5 days; if widespread may require oral antibiotics; 5-7 days and goes away

bacterial rashes: staphylococcal scalded skin syndrome

• staph is a normal bacteria found on all of our skin

  • staph aureus bacteria releases a toxin that travels through the bloodstream and binds with a protein on the outer layer of skin

  • if cut or dec immunity, susceptible to infection

• rough textured skin with macular erythema, results in painful blistering and sloughing of the skin- around neck, face, and then spreads

  • present with low-grade fevers and can get higher

  • typically affects those under age 6

  • hard to comfort child because it is really painful and can be under armpits which hurts to pick them up

• treatment: fluids, barrier ointment, pain med, antibiotics

  • ointment may not be best because of pain with touch

  • abx for atleast 3 days to tx

  • replenish with IV fluids- if in mouth they won’t want to eat or drink

bacterial rashes: acne

• hair follicles/ pores clogged with oil (sebum) and dead skin cells

  • open or closed comedones (flush, white, red), erythematous

• bacterial from surface of skin

  • androgen production

• nursing considerations:

  • exacerbating factors: diet, touching face, harsh washing, stress, hormones

• treatment:

  • wash face BID, with mild cleanser

  • topical keratolytic: tretinoin-retinoid

  • topical antibacterial: benzoyl peroxide, clindamycin

  • sometimes: PO doxy or minocycline

  • OCP’s with low androgen effect or spironolactone for hormonal acne

  • if cystic or complicated: intra-lesional steroid or oral retinoid therapy (accutane- reduces oil on skin to dry out acne) may be started under derm supervision and requires lab studies

bacterial rashes: lyme disease

• most common tick-borne illness in the US

  • caused by spirochete borrelia burgdorferi

  • symptoms: fever, HA, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough

• 3 stages of disease development:

  • 3-30 days, tick bite: inoculation

  • 3-10 weeks post bite: disseminated disease

  • 2-12 months: systemic involvement- neuro changes

• nursing considerations

  • classical annular erythema chronicum migrans (70% of people with Lyme)

  • prevention: long/ light colored clothing, repellent, tick checks, treat animals

• diagnosis: based on history, serology, or testing not recommended

• treatment: once rash appears or if you know you had a bite, if > 8 years old- start doxy treatment, if <8 give amoxicillin

  • clean with warm water and soap or alcohol

Fungal rashes: diaper candidiasis

• caused by candida yeast, usually C. Albicans

  • satellite lesions (all over, not congruent) and involvement of deep folds/ creases

• nursing considerations:

  • when you see a diaper candidiasis, oral thrush must also be ruled out- can be systemic

  • most often see in neonates and immunocompromised people

• treatment is antifungal cream x2-3 weeks

  • clotromazole or nystatin

  • about 2x per day and keep as dry as possible

  • dont give powder to kids- can go into airways

Fungal rashes: tinea capitis/ corporis: ringworm

• fungal infection of hair follicles or body (ringworm is not caused by a worm!)

  • tinea capitis (ringworm of the scalp)

  • tinea corporis (ringworm of the body)

• scaling is hallmark! white spots

• treatment: topical antifungals for up to 6 weeks

  • more widespread infection may require systemic antifungal med

  • do not use topical steroids → cause immunosuppression; worse for healing of fungal infection; can prolong/ spread infection

Fungal rashes: dermatitis

• acute or chronic inflammation of dermis

  • contact dermatitis

  • seborrheic dermatitis

  • atopic dermatitis (eczema) in response to allergen

• causes: contact with irritant leads to skin inflammation and hypersensitivity reaction; typically an allergic rxn

• treatment: remove irritant

  • cleanse, soothing lotions, barrier ointments, systemic antihistamine

• very bad cases may require systemic steroids

Fungal rashes: diaper dermatitis

• contact dermatitis caused by contact with urine/ fecal matter

• spares creases

• nursing considerations:

  • often compounded by occlusive environment of the diaper

  • parent and family education

• treatment:

  • thick barrier creams (aquaphor, zinc oxide containing), water-only wipes, water-only bathing, open to air-time, sometimes topical medications

  • often desitin then aquaphor to repell water

Fungal rashes: seborrheic dermatitis: cradle cap

• cause: overproduction of sebum- benign

• oily crusts, usually limited to scalp but can progress to face and behind ears

• treatment: benihn neglect (time), GENTLE brushing, emollients, anti-seborrheic shampoos, tea tree oil, hydrocortisone cream or topical anti-fungal cream

Burns

• infants and children have proportionally larger heads and smaller lower extremities; total BSA is different from adults

  • know there is an increase in severity because of less and more fragile skin

• thinner pediatric skin= increased severity and thickness of burns even with the same mechanism of injury

  • thinner skin = inc severity

• nursing considerations:

  • burns to hands, feet, and face should be evaluated by a specialist

  • dehydration

  • infection- barrier of skin disrupted

  • pain

  • wound care

• treatment

  • similar to adult tx

  • PO/ IV fluids

  • protective barriers

  • prophylactic abx

  • non-adherent dressings, cream

  • VS assessments frequently

  • promote optimal nutrition

Petechiae and purpura

• not a rash but can appear as one

• caused by bleeding of the superficial vessels of the skin

• petechiae: pinpoints to <1cm

• purpura: larger

• non-blanching, which helps to distinguish from inflammatory concerns